Transitioning to Sustainable Healthcare: Decarbonising Healthcare Clinics, a Literature Review

Round 1

Reviewer 1 Report

This is a very interesting paper exploring research on decarbonising in healthcare industry. The manuscript has focused on the principles and areas to act upon to decarbonise a healthcare clinic with reference to Australia.

Some comments and suggestions as minor revisions are provided below so that the author takes them into consideration:

1. The section of Background should be in the Introduction before the method and material section.

2. Due to the long section of 4. Results and discussion, I would suggest the author check the possibility to separate them and classify several important topics to discuss in the discussion section.

3. Line 637, 641, 643: inconsistency of citation format. 

Author Response

Thank you for your review and your comments, these were very useful. Please see below a point-by-point response to the comments. 

1. The section of Background should be in the Introduction before the method and material section.

I agree that the Background section often comes before the Methods section in various articles. In this article's circumstance, I argue that due to the nature of the topic, it may make more sense to a reader to digest the introduction section for an overview of what the paper is about, then go on to the methods section to understand how the author has gone about the research, which then leads into a more detailed background section for more in-depth context before the results.

1. Due to the long section of 4. Results and discussion, I would suggest the author check the possibility to separate them and classify several important topics to discuss in the discussion section.

Actioned, thank you. 

1. Line 637, 641, 643: inconsistency of citation format

These have been corrected, thank you for pointing this out. 

Thank you again for your review, I do appreciate your time. 

Reviewer 2 Report

First of all, congratulate the author for the submitted manuscript. It is a very actual and extremely relevant topic.

The manuscript "Transitioning to sustainable healthcare: Decarbonising healthcare clinics" aims to synthesize state-of-the-art initiatives, barriers and opportunities to make healthcare clinics more environmentally sustainable.

The manuscript has 30 pages, including reference pages. 118 references are presented, mostly less than 5 years old (more than 75% of the references).

The manuscript is divided into abstract, introduction, materials and methods, background, results and discussion (grouped), and conclusion.

Next, I will present some reflections that came to my mind after reading the submitted manuscript.

Regarding the title

As the manuscript is a literature review, it may be useful to include "literature review" in the title. It may help with future quotes.

Regarding the "introduction" section

The author identifies the problem under study.

Regarding the "materials and methods" section

1) The author states that he has undertaken initial research, of an exploratory nature, to identify the current state of clinical/business sustainability awareness and action in Australia. For what purpose? The aim "to identify the current state of clinical/business sustainability awareness and action in Australia" is ultimately the aim of this review. It makes sense, to do an initial search to check whether or not there is already a publication with the same object of study and with the same objectives, or to check if there is already a published review protocol, but in that sense it was necessary to do research in PROSPERO and in OSF.

2) The author mentions that a structured literature review was carried out. Was a review framework followed? (like cocherane or Joanna Briggs Institute)

3) The search was limited to publications from 2010 onwards. Why only from 2010 anwards?

4) The author mentions that the data analysis included discourse analysis. Discourse analysis is a field of linguistics and communication specialized in analyzing the use of natural languages, particularly the way ideological constructions occur in a text. Discourse analysis is used for qualitative studies. Is this a qualitative study or a literature review? If the author mentions that discourse analysis (analyzing the context and meaning of words and concepts), which made it possible to quantify "patterns and trends seen in articles specifically designed to identify attitudes, barriers and opportunities for the transition to sustainability", what concepts intended to analyse?

5) Was a data extraction grid used? For example, a table to obtain the data that support the objectives of the study: identification of the publication, year of publication, type of publication, purpose of publication (if applicable), context (if applicable), barriers/challenges/opportunities/ attitudes identified in the publication.

Regarding the "background" section

The main implications of climate change on health and health systems are identified, as well as the problem of the ecological footprint of the health-related industry.

Regarding the "results and discussion" section

1) Why did the author merge results and discussion sections? Wouldn't it be useful to know how many publications/articles were included in this review?

2) If the author mentions that he performed discourse analysis, wouldn't it be useful to present a matrix of concepts and codifications to better understand the type of analysis?

3) In lines 595–597, the idea presented implies that the solution already exists on the market. Does it already exist or is it still a prototype? In the reference of the article it is mentioned that further studies are needed.

4) Regarding lines 703–709: What does the author have to say about the constant need to acquire equipment, due to the rapid technological evolution in the health area, which also makes people want to have the best and most innovative treatment ? Is it a management and financial problem, or a problem of responding to the population's expectations?

5) Lines 877–879 read "healthcare professionals, doctors in particular, command societal respect from the public, they are trusted messengers when advocating for decarbonisation of the healthcare system". The largest health professional class are nurses and all studies indicate that nurses are the health professionals that the population trusts the most.

Regarding of other aspects:

1) Line 576: Citation is not in line with the references style. Reference 75?

2) Lines 637, 641 and 643: citations do not conform to the style of references. Reference 90?

3) In the "references" section, reference 63 has no date (bearing in mind that it is a website, it must have the date of access).

4) The resolution of the figures should be better. The low quality makes reading 1 and 4 difficult.

5) Given the current length of the manuscript I strongly advise the author to avoid some repetition of ideas in the "results and discussion" subheadings. A slightly shorter version of the manuscript will increase interest amongst the average reader.

Author Response

Firstly, thank you for reviewing the paper and for the feedback. It was very useful. I appreciate you drawing my attention to the details you have mentioned so I can improve this paper. Please find below point-by-point comments in regard to your review.  

As the manuscript is a literature review, it may be useful to include "literature review" in the title. It may help with future quotes.

Thank you for this suggestion. I have added this to the title. I have also removed "challenges and opportunities" from the title of the original submission (see below when addressing the methods section for more information as to why).

Regarding the "materials and methods" section

1) The author states that he has undertaken initial research, of an exploratory nature, to identify the current state of clinical/business sustainability awareness and action in Australia. For what purpose? The aim "to identify the current state of clinical/business sustainability awareness and action in Australia" is ultimately the aim of this review. It makes sense, to do an initial search to check whether or not there is already a publication with the same object of study and with the same objectives, or to check if there is already a published review protocol, but in that sense it was necessary to do research in PROSPERO and in OSF.

This manuscript was originally a Master's thesis composed of two parts. A structured literature review combined with primary data collection in the form of an online survey of healthcare clinic owners. The survey asked health clinic owners about their thoughts on healthcare decarbonisation and explored barriers and opportunities to transition to more sustainable practices. As the thesis was over 20,000 words I was advised that to develop the thesis into a manuscript fit for academic journal publication, I should split the two components. The manuscript here is the literature review part. As such none of the results of the online survey have been spoken about or included in this manuscript. This is why the initial exploratory research read as you have quoted above. I have amended this to make it more specific to the more narrow results of this part of the research.  

2) The author mentions that a structured literature review was carried out. Was a review framework followed? (like cocherane or Joanna Briggs Institute)

Following on from the above answer. As this was originally a literature review combined with primary data collection, my supervisor deemed it unnecessary to conduct a systematic literature review stating that a structured literature would be sufficient. Looking at this retrospectively, knowing what I now know on this topic, I am confident that conducting a systematic literature review following a framework would not have revealed much new information that was not picked up by the structured review as this is a relatively new area of study (decarbonising healthcare clinics as opposed to hospitals) and I was very rigorous and organised with the structured review (just no formal framework was used).

3) The search was limited to publications from 2010 onwards. Why only from 2010 anwards?

I simply wanted to keep my data/information current. As I am sure you know, literature concerning climate change, emissions reduction and decarbonisation is and has been changing relatively quickly.

4) The author mentions that the data analysis included discourse analysis. Discourse analysis is a field of linguistics and communication specialized in analyzing the use of natural languages, particularly the way ideological constructions occur in a text. Discourse analysis is used for qualitative studies. Is this a qualitative study or a literature review? If the author mentions that discourse analysis (analyzing the context and meaning of words and concepts), which made it possible to quantify "patterns and trends seen in articles specifically designed to identify attitudes, barriers and opportunities for the transition to sustainability", what concepts intended to analyse?

This was my mistake for leaving this sentence in the manuscript. Discourse analysis, as you have correctly pointed out is used for qualitative data. I used this type of anaylsis for my survey data not for the literature review part of this research. This section has been amended. 

5) Was a data extraction grid used? For example, a table to obtain the data that support the objectives of the study: identification of the publication, year of publication, type of publication, purpose of publication (if applicable), context (if applicable), barriers/challenges/opportunities/ attitudes identified in the publication.

A data extraction grid was not used for the reasons mentioned above. I have included the search terms (see amended methods sections for more info). I am also more than happy to send through my completed thesis paper which details the overall methods of how I conducted this research, if you would find it useful to view. I have just not included sections of it in this manuscript as it makes more sense when combined with the primary data collection part of the original paper. 

Regarding the "background" section

The main implications of climate change on health and health systems are identified, as well as the problem of the ecological footprint of the health-related industry.

Regarding the "results and discussion" section

1) Why did the author merge results and discussion sections? Wouldn't it be useful to know how many publications/articles were included in this review?

I have now split these two sections. As mentioned, as this was a structured literature review as opposed to a systematic review, the number of articles was not recorded. I am now aware this was an oversight to not record this figure. 

2) If the author mentions that he performed discourse analysis, wouldn't it be useful to present a matrix of concepts and codifications to better understand the type of analysis?

See the answer above. 

3) In lines 595–597, the idea presented implies that the solution already exists on the market. Does it already exist or is it still a prototype? In the reference of the article it is mentioned that further studies are needed.

Thank you, this idea/paragraph has been re-writted to be more accurate. 

4) Regarding lines 703–709: What does the author have to say about the constant need to acquire equipment, due to the rapid technological evolution in the health area, which also makes people want to have the best and most innovative treatment ? Is it a management and financial problem, or a problem of responding to the population's expectations?

Thank you, that is a great point, this section has been changed to address this question.  It is mentioned now in another section. 

5) Lines 877–879 read "healthcare professionals, doctors in particular, command societal respect from the public, they are trusted messengers when advocating for decarbonisation of the healthcare system". The largest health professional class are nurses and all studies indicate that nurses are the health professionals that the population trusts the most.

Thank you, this has been amended. 

Regarding of other aspects:

1) Line 576: Citation is not in line with the references style. Reference 75?

Been corrected

2) Lines 637, 641 and 643: citations do not conform to the style of references. Reference 90?

Been corrected

3) In the "references" section, reference 63 has no date (bearing in mind that it is a website, it must have the date of access).

Been corrected

4) The resolution of the figures should be better. The low quality makes reading 1 and 4 difficult.

Figure 1 I could not enhance or change, Figure 4 has been replaced with a higher-quality picture. 

5) Given the current length of the manuscript I strongly advise the author to avoid some repetition of ideas in the "results and discussion" subheadings. A slightly shorter version of the manuscript will increase interest amongst the average reader.

Thank you, the manuscript has been shortened significantly.